Management and Treatment of Temporomandibular

Disorders: A Clinical Perspective

EDWARD F. WRIGHT, DDS, MS1; SARAH L. NORTH, PT, MPT2

A
temporomandibular disorder musculoskeletal disorders of other parts mouth or wherever the tongue is most
(TMD) is a musculoskeletal dis- of the body, and therapeutic approaches comfortable) and keeping the teeth apart
order within the masticatory sys- for other musculoskeletal disorders gen- and masticatory muscles relaxed1,2,5.
tem. Many practitioners refer to TMD erally apply to this disorder as well1,2,4. As with other musculoskeletal dis-
as a single disorder in spite of the fact Similar to other repetitive motion disor- orders, pain during function and/or at
that patients have various sub-diagno- ders, TMD self-management instruc- rest is the primary reason patients seek
ses (e.g., myofascial pain, temporoman- tions routinely encourage patients to treatment, and reduction in pain is gen-
dibular joint (TMJ) inflammation)1,2. rest their masticatory muscles by volun- erally the primary goal of therapy1,2.
TMD is a prevalent disorder most com- tarily limiting their use, i.e., avoiding Less commonly, individuals seek TMD
monly observed in individuals between hard or chewy foods and restraining therapy for TMJ catching or locking,
the ages of 20 and 40. Approximately from activities that overuse the mastica- masticatory stiffness, limited mandibu-
33% of the population has at least tory muscles (e.g., oral habits, clenching lar range of motion, TMJ dislocation,
one TMD symptom and 3.6% to 7% teeth, holding tension in the masticatory and unexplained change in their occlu-
of the population has TMD with suffi- muscles, chewing gum, and yawning sion (anterior or posterior open bite, or
cient severity to cause them to seek wide)1,2,5. The self-management instruc- shift in their mandibular midline).
treatment1-3. tions also encourage awareness and However, TMJ noises are common
TMD is often viewed as a repetitive elimination of parafunctional habits among the general population, are gen-
motion disorder of the masticatory (e.g., changing teeth clenching habit to erally not a concern for individuals or
structures. It has many similarities to lightly resting the tongue on top of the practitioners, are not commonly treated,
and do not generally respond as well to
therapy as pain1,2,6-9. The purpose of this
clinical perspective is to describe the ex-
ABSTRACT: A temporomandibular disorder (TMD) is a very common problem affecting amination and treatment of TMD from
up to 33% of individuals within their lifetime. TMD is often viewed as a repetitive motion both a dentist’s and a physical therapist’s
disorder of the masticatory structures and has many similarities to musculoskeletal disor- perspective.
ders of other parts of the body. Treatment often involves similar principles as other regions
as well. However, patients with TMD and concurrent cervical pain exhibit a complex symp-
tomatic behavior that is more challenging than isolated TMD symptoms. Although rou- Dentist’s TMD Examination
tinely managed by medical and dental practitioners, TMD may be more effectively cared for TMD pain is generally located in the
when physical therapists are involved in the treatment process. Hence, a listing of situations masseter muscle, preauricular area, and/
when practitioners should consider referring TMD patients to a physical therapist can be or anterior temporalis muscle regions.
provided to the practitioners in each physical therapist’s region. This paper should assist The quality of this pain is generally an
physical therapists with evaluating, treating, insurance billing, and obtaining referrals for ache, pressure, and/or dull pain and may
TMD patients. include a background burning sensa-
KEYWORDS: Dentistry, Physical Therapy, Temporomandibular Disorders, Temporo- tion. There may also be episodes of sharp
mandibular Joint pain, and when the pain worsens, the
primary pain quality may become a

1
Associate Professor, Department of Restorative Dentistry, University of Texas Health Science Center at San Antonio
2
Hill Country Physiotherapy Associates, San Antonio, TX
Address all correspondence and requests for reprints to: Edward Wright, DDS, MS, wrighte2@uthscsa.edu

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 MANAGEMENT AND TREATMENT OF TEMPOROMANDIBULAR DISORDERS: A CLINICAL PERSPECTIVE
throbbing sensation. Patients with TMD
tend to report that their pain is intensi-
fied by events such as stress, clenching,
and eating, while it is relieved by relax-
ing, applying heat to the painful area,
and taking over-the-counter analge-
sics1,4,5,10.
As practitioners obtain a patient’s
pain history, they must be alert for un-
usual pain locations, pain qualities,
pain-aggravating and pain-relieving
events, and other factors (e.g., unex-
plained fever) suggestive of disorders
that may mimic TMD symptoms (e.g.,
infection, giant cell arteritis, meningitis,
etc.)2,5. Practitioners must also inquire
about other diseases or symptoms that
may negatively impact the patient’s re-
sponse to the practitioner’s therapies.
For instance, studies suggest that TMD
patients with cervical or widespread
pain will not obtain the same degree of
improvement as other TMD patients
who do not have these pains11-13. Thus,
practitioners may desire to refer these
patients for treatment of these disorders.
For example, the patient may be referred
to a physical therapist primarily for
treatment of the cervical region, but ad-
ditionally for supplementary therapy for
the masticatory region2,14.
A thorough physical examination
entails evaluating the mandibular range
of motion (Figure 1); the minimum of
normal is a 40 mm opening, 7 mm to the
right and to the left movements, and a
6 mm protrusive movement2,5,15. If the
patient has a restricted opening, the
practitioner may be able to determine its
origin by stretching the mouth wider.
This is usually performed by placing the
index finger over the incisal edges of the
mandibular incisors and the thumb over
the incisal edges of the maxillary inci-
sors and pressing the teeth apart by mov-
ing the fingers in a scissor-type motion2.
The patient will usually feel tightness or
pain at the location of the restriction,
and the patient is asked to point to this
location. The location is confirmed by
the practitioner palpating that location2.
In the thorough physical exam, the
practitioner will also intensify or repro-
duce the patient’s masticatory pain and
then rule out structures outside the mas-
ticatory region as sources of the pain1,2,16.
It is recommended that the masseter and
[248] THE JOURNAL OF MANUAL & MANIPULATIVE THERAPY Q VOLUME 17 Q NUMBER 4
anterior temporalis muscles (Figure 2)
and the TMJs (Figure 3) be palpated to
ensure that this intensifies or reproduces
the patient’s pain and to determine
whether the primary pain source is mus-
cle or TMJ1,2,14,17,18. It is also recom-
mended that the thyroid, carotid arter-
ies, and suboccipital and postural
musculature be palpated to determine
whether they cause or contribute to the
pain complaint; if they do, a referral may
be indicated2,17,18.
If the patient’s pain was not inten-
sified or reproduced with the palpatory
examination, the practitioner may
more intensely palpate the previously
palpated structures, may locate and
palpate the myofascial trigger points
within the previous structures, or may
attempt to reproduce the patient’s pain
from different locations19-21. The deci-
sion varies with the practitioner’s sus-
picions and clinical experience. Figure
4 provides maps of palpation locations
that have been shown to generate re-
ferred pain to the labeled anatomical
areas of the head and face. Referred
pain patterns tend to be consistent
from patient to patient, so readers may
find these maps beneficial for any pa-
tient with head or face pain when the
true source of the patient’s pain has not
been identified19-21.
When evaluating a patient for pain,
first evaluate for local causes. For ex-
ample, if an individual has ear pain, it is
best if he or she is evaluated by a physi-
cian to determine if there is a local cause
for this pain2,19,21. Similarly, it is common
for dentists to receive a referral for pa-
tients with ear pain where a physician
has ruled out a local cause for the pain
(e.g., ear infection) and the physician
suspects TMD16,19.
Studies confirm that about one-
third of these patients have ear pain that
is referred from TMD, one-third have
pain that is referred from a cervical
spine disorder (CSD), and one-third
have pain referred from both TMD and
CSD22,23. To determine the source(s),
Figure 1 can be used to identify the loca-
tions to palpate that have been shown to
cause ear pain. Based upon the identi-
fied tenderness and the ease of the
various palpated structures in intensify-
ing or reproducing the ear pain, the
practitioner can more easily determine
whether it would be most cost-effective
to provide this patient with TMD ther-
apy, refer the patient to a physical thera-
pist for CSD therapy, or recommend
both therapies2.
Another example of identifying the
source of referred pain is a patient who
complains of forehead pain when local
structures (e.g., sinuses) have been ruled
out as the cause of this pain. Practitio-
ners may want to palpate the structures
that have been found to commonly refer
pain to the forehead (Figure 4). If palpa-
tion of cervical muscles reproduces
the patient’s forehead pain, this suggests
that the cervical musculature could
cause or contribute to this pain and it is
generally worthwhile to conservatively
treat (e.g., through physical therapy) the
cervical musculature and see if this pro-
vides satisfactory relief of the forehead
pain2.
As part of the clinical exam, it is rec-
ommended that dental practitioners vi-
sually perform an intraoral screening,
evaluating for evidence of pathology,
such as swelling, cavities, deflection of
the soft palate when saying “ah,” etc. The
patient’s history will often have alerted
the practitioner to oral disorders that
may be causing or contributing to the
symptoms and which may indicate that
additional radiographs or tests are
needed. Generally, only a screening ra-
diograph, such as a panoramic radio-
graph, is needed in the evaluation of the
majority of TMD patients2,5,17,18.
To varying degrees, practitioners
are able to identify contributing factors
that appear to be perpetuating the
TMD symptoms and the magnitude
to which they are contributing to
the symptoms. Examples of commonly
identified TMD perpetuating factors
are nighttime parafunctional habits,
gum chewing, daytime clenching, hold-
ing tension in the masticatory muscles,
neck pain, excessive caffeine consump-
tion, stress, tension, aggravations, frus-
trations, depression, poor sleep, poor
posture, and widespread pain. It is rec-
ommended that the contributing fac-
tors that are the easiest to change and
that are speculated to provide the
greatest impact on the symptoms be
initially changed1,2,4,17,24.
 MANAGEMENT AND TREATMENT OF TEMPOROMANDIBULAR DISORDERS: A CLINICAL PERSPECTIVE

FIGURE 1. (ABOVE LEFT) Measuring the opening

mandibular range of motion.
FIGURE 2. (TOP RIGHT) Palpating the anterior
temporalis muscles.
FIGURE 3. (BOT TOM RIGHT) Palpating the
temporomandibular joints.

Management Protocol
Many therapies have been advocated for
treating TMD, and many health profes-
sionals have found that they are able
to help patients improve TMD symp-
toms. The practitioner managing the
patient’s therapy should decide which
therapies are most cost-effective and
evidence-based, and which have the
greatest potential to provide the patient
with long-term symptom relief. The
most cost-effective therapies are the
TMD self-management therapies, spe-
cifically when use is continuous and ad-
hered to1,2,24.
A therapy that is commonly pro-
vided by dentists is an occlusal orthotic,
also called a dental or occlusal appliance
or a splint (see Figure 5). The appliance
can be made to cover the occlusal sur-
faces of maxillary or mandibular teeth
and can be fabricated from many differ-
ent materials, giving it a hard, soft, or
intermediate feel. It is generally pre-
ferred that the appliance be worn only at
night and possibly a few hours during
the day when the patient has not yet bro-
ken the habit of heavy clenching activity
(e.g., while driving a car). It is rare for
patients to be willing to wear the or-
thotic in public because it generally in-
terferes with speech and is somewhat
unattractive1,2,5,17,25.
Occlusal orthotics are beneficial for
masticatory muscle pain, TMJ pain,
TMJ noises, restricted jaw mobility, and
TMJ dislocation1,2,5,25. If the appliance is
worn at night, it has its most dramatic
effect on the TMD symptoms that pa-
tients have upon awaking. Therefore, an
occlusal orthotic can be fabricated pri-
marily to relieve symptoms in patients
who have TMD symptoms on wak-
ing1,3,5,26,27. It is our impression that if a
patient’s pain is limited to the mastica-
tory system and the patient has minimal
psychosocial contributors, we can satis-
factorily reduce the symptoms without
referral. If the patient has a CSD that is
worthy of treatment, he or she should
usually be referred to a physical thera-
pist for treatment2,14.
The dentist author has, to date, rec-
ommended a physical therapy referral
for approximately 50% of his TMD pa-
tients28. He would generally like the
physical therapist to treat the cervical
component and help resolve the masti-
catory component1,2,5,12. The situations
in which it is recommended that practi-
tioners consider referring TMD patients
to a physical therapist are listed in Table
1. Conversely, there are situations in
which it is recommended that physical
therapists consider referring a TMD pa-
tient to a dentist (Table 2). For example,
if a TMD patient is waking with TMD
pain, this suggests nocturnal factors are
contributing to the symptoms. If stom-
ach sleeping has been corrected or ruled
out, it is recommended that the patient
be provided with an occlusal orthotic to
decrease pain on waking1,3,26,27.
Patients who have tooth pain gener-
ally also have facial pain5,29. As with
other referred pains, patients occasion-
ally perceive the site of their pain as the
source of the referred pain and attempt
to have the site treated rather than the
source5. Consequently, a physical thera-
pist may target treatment for TMD when
the true pain source is actually a tooth.
Some situations that suggest that a tooth,

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 MANAGEMENT AND TREATMENT OF TEMPOROMANDIBULAR DISORDERS: A CLINICAL PERSPECTIVE

FIGURE 4. (ABOVE) Locations responsible for

producing referred pain to the different regions of
the head.*
*The superficial sites that have caused referred pain to the
labeled regions of the head are highlighted on the drawing
and the intraoral palpation locations are listed below the
drawing.

FIGURE 5. (RIGHT) An occlusal orthotic on a

cast of the patient’s teeth.

rather than TMD, is the source of the
patient’s pain include the patient relat-
ing that 1) the pain occurs or intensifies
upon drinking hot or cold beverages, 2)
throbbing pain occurs spontaneously, or
3) throbbing pain wakes him or her up
from sleep (there can be other causes for
this symptom, e.g., neck pain). In about
3% of the patients referred to the dentist
author for “TMD,” after thorough ex-
amination, a tooth is found to be the true
source of the pain. The tooth may need
to receive root canal therapy or to be ex-
tracted5,16,30.
Treatment Approaches for TMD
There are several theories on best thera-
pies for TMD. None of these theories is
perfect, but the one that appears to best
target the various patients and their con-
tributing factors correlates treatment
strategies with patients’ daily variations
in symptoms31,32. For example, some
TMD patients awake with TMD pain
that only last minutes to hours, suggest-
ing that nocturnal factors are the pri-
mary contributors to these symp-
toms2,3,5,26,27. Other TMD patients awake
symptom-free and their TMD symp-

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 MANAGEMENT AND TREATMENT OF TEMPOROMANDIBULAR DISORDERS: A CLINICAL PERSPECTIVE

toms develop later in the day, suggesting
that daytime factors are the primary
contributors to these symptoms (e.g.,
daytime muscle tensing or clenching
habits). TMD patients in a third group
may report that they awake with TMD
pain that never goes away, suggesting
that both nocturnal and daytime factors
are contributing to their symptoms. In
this third patient group, patients gener-
ally report that either their awaking or
daytime symptoms are worse, suggest-
ing that the nocturnal or daytime factors
are more significantly contributing to
their symptoms2,5,31,32.
Therapies shown to be beneficial for
TMD symptoms that patients awake
with are provided in Table 2. Therapies
shown to be beneficial for daytime TMD
symptoms are provided in Table 3. There
are also therapies that appear beneficial
for both awaking and daytime TMD
symptoms; they are provided in Table 4.
Some TMD therapies are not listed be-
cause the authors do not routinely use
them; these methods have no demon-
strated evidence within the literature or
there is inconsistent clinical sense for
their effect on symptom patterns2,5,10.
For a patient who awakes with
TMD symptoms, decide which thera-
pies in Tables 2 and 4 have the greatest
potential to provide the most cost-effec-
tive, long-term symptom relief. For a
patient who awakes symptom-free and
the TMD symptoms develop later in the
day, similarly consider therapies in Ta-
bles 3 and 4. For a patient who awakes
with symptoms and has them through-
out the day, consider all the therapies
(Tables 2, 3, and 4), keeping in mind the
predominant category2.
It is recommended that these thera-
pies be modulated with the symptom
severity, anticipated compliance, abili-
ties of providers (dentist, physical thera-
pist, psychologist, etc.), impact on the
patient’s lifestyle (for both symptoms
and treatments), and cost (in terms of
price, time, adverse sequelae, etc.). It is
recommended that the least invasive

TABLE 1. Situations when it is recommended that dental practitioners consider referring TMD patients to a
physical therapist.

Mechanism Situation
Cervical The patient has neck pain worthy of treatment.
The patient has cervicogenic headaches (headaches that can be reproduced by palpating the neck).
Postural The patient has moderate to severe forward head posture; a study suggests these patients may obtain significant TMD
symptom improvement from posture exercises in combination with TMD self-management instructions.
The patient’s TMD symptoms increase with abnormal postural activities.
The patient desires help in changing poor sleep posture (e.g., stomach sleeping).
Outcome-Oriented The patient did not obtain adequate TMD symptom relief from initial therapies that did not include physical therapy.
The patient is to have TMJ surgery; patients who receive physical therapy after TMJ surgery may have significantly
better results. It is appropriate for these patients to be referred for physical therapy prior to surgery in order that
they may learn about and possibly start the postsurgical exercises, schedule the recommended postsurgical
appointments, and receive prior authorization from their insurance carrier.

TABLE 2. Situations when it is recommended that physical therapy practioners refer TMD patients to a dentist and
appropriate treatment mechanisms.

Time Factor Event Treatment

Nocturnal The patient awakes with TMD pain. t Improve sleep positions.
t Wear an occlusal orthotics at night.
t Prescribe medications that decrease electromyelographic (EMG)
activity (e.g., amitriptyline (10 mg, 1–5 tabs 1–6 hours prior to
bedtime), nortriptyline (10 mg, 1–5 tabs 0–3 hours prior to bedtime),
or diazepam
(5 mg, 1–2 tabs).
t Relaxation prior to sleep.

Daytime The patient has symptoms associated with Comprehensive dental examination and treatment.
tooth-related pain such as:
t Pain occurs or intensifies upon drinking hot or
cold beverages.
t Throbbing pain occurs spontaneously.
t Throbbing pain awakes him or her from sleep
(there can be other causes for this symptom,
e.g., neck pain).

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 MANAGEMENT AND TREATMENT OF TEMPOROMANDIBULAR DISORDERS: A CLINICAL PERSPECTIVE

TABLE 3. Therapies that have been shown to be beneficial for daytime TMD symptoms.

Orientation Treatment
Relaxation/Stress Management t
Breaking daytime parafunctional and muscle-tensing habits.
t
Learning to relax masticatory muscles and maintain this relaxed state throughout the day.
t
Learning stress management and coping skills for life’s irritations.
t
Performing biofeedback to help learn to relax masticatory muscles.

Orthotic t
Wearing an occlusal orthotic during the day (as a temporary crutch until daytime habits are broken
or to increase awareness of daytime habits and facilitate breaking them).
Medicative t
Prescribing a tricyclic antidepressant that can be taken during the day [e.g., desipramine (25 mg,
1 tab in the morning and afternoon)].

* Some treatment effects generally carry over to the other portion of the day, so patients who have mild daytime pain may find that nocturnal wear of occlusal
orthotic provides satisfactory symptom relief.

TABLE 4. Therapies that appear beneficial for both awaking and daytime TMD symptoms.

Orientation Treatment
Medicative Prescribing NSAIDs and/or steroids.
Passive Approach Performing physiotherapy modalities (heat, ice, ultrasound, iontophoresis, etc.).
Performing jaw-stretching exercises.
Active Approach Performing head and neck posture improvement exercises.
Indirect Approach Performing cervical therapies (manual techniques, neuromuscular re-education, etc.).

procedures be used first and if this ade-
quately resolves the pain, no other treat-
ment is needed. It is appropriate for pa-
tients to wear an occlusal orthotic at
night for as long as it is beneficial1,2.
Additionally, consider non-TMD
disorders that may negatively impact the
patient’s TMD symptoms, such as neck
pain, widespread pain, rheumatic disor-
ders, sinus pain, poor sleep, and de-
pression. Failure to obtain adequate
improvement of these non-TMD con-
tributors decreases the probability of pa-
tients achieving satisfactory TMD
symptom improvement1,2. A significant
number of TMD patients have a cervical
component contributing to or perpetu-
ating the TMD symptoms.
Surgery is rarely needed for TMD
patients. One study that tracked over
2,000 TMD patients from many prac-
tices found that only 2.5% underwent
TMJ surgery (1.4% arthrocentesis, 1.0%
arthroscopy, and 0.1% open joint proce-
dures)33. Other than for the obvious rea-
sons (e.g., infection, fracture, or neo-
plastic growth), there are primarily three
TMD disorders for which patients are
referred to a surgeon: 1) TMJ inflamma-
tion, 2) acute TMJ disc displacement
without reduction (closed lock), and 3)
TMJ ankylosis (painless severe limited
opening)2.
Current Best Evidence in Physical
Therapy Treatment
For many years, physical therapy has
been used to treat TMD symptoms;
however, the evidence supporting its use
is limited. In this article, physical ther-
apy treatments are assumed to include
manual techniques (i.e., stretching, mo-
bilizations, and manipulations of the
TMJ and cervical spine); exercise in-
struction (i.e., self stretching and mobil-
ity strategies for the TMJ and cervical
spine); patient education (i.e., postural
instruction, relaxation techniques, and
parafunctional awareness); and modali-
ties that improve tissue health.
One recent systematic review of the
literature on the efficacy of physical
therapy interventions for TMD patients
found 36 relevant articles, of which 12
met their selection criteria. Only 3 were
found “to be of strong methodological
quality”34, and 4 of the 12 were dedicated
to exercise and manual interventions,
and only one did not demonstrate sig-
nificant benefit from the chosen treat-
ment strategy (an oral exerciser device).
The remaining 3 studies evaluated pos-
tural training, manual therapy, and exer-
cise, and all demonstrated significant
benefit34. The best Jadad score35 obtained
for the 4 studies was a 234. This system-
atic review concluded that “active and
passive oral exercises and exercises to
improve posture are effective interven-
tions to reduce symptoms associated
with TMD”34.
A second recent systematic review
that evaluated the literature on the effi-
cacy of physical therapy interventions
for TMD patients concluded that active
exercise and manual mobilizations may
be effective as well as postural training
in combination with other TMD inter-
ventions36. This review favored the use of
multifaceted TMD treatment strategies,
which coincided the with review au-
thors’ opinions. According to Sackett’s
rules of evidence37, in general, the study

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 MANAGEMENT AND TREATMENT OF TEMPOROMANDIBULAR DISORDERS: A CLINICAL PERSPECTIVE
quality was level II for 22 of the 36 stud-
ies reviewed36.
Further validation for physical
therapy’s effectiveness with TMD pa-
tients has been published since these
two systematic reviews. In general, va-
lidity and strength of the studies were
weak; however, continued evidence sup-
ports that physical therapy may be effec-
tively used as a stand-alone and/or, more
effectively, used in a team approach with
other conservative TMD therapies38-41.
One study suggested that Osteopathic
Manipulative Treatment can induce
changes in the stomatognathic dynam-
ics, offering a valid support in the clini-
cal approach to TMD”38. A second con-
cluded that “physical therapy seems to
have a positive effect on treatment out-
comes of patients with TMD”39. A third
found that “the combination of orofacial
myofunctional therapy and an occlusal
splint can be beneficial for patients with
TMD-hypermobility”40. An additional
study compared four treatment strate-
gies for TMJ close-lock: medical man-
agement (education, counseling, self-
help, and NSAIDS); rehabilitation
(occlusal orthotic, physical therapy, and
cognitive-behavioral therapy); arthros-
copy with post-operative rehabilitation;
and arthroplasty with post-operative re-
habilitation (i.e., physical therapy). The
results demonstrated that “the four
treatment strategies did not differ in
magnitude or timing of improved func-
tion or pain relief ”41. Since the four
treatment strategies had similar efficacy,
the authors of this article believed that
the most cost-effective and conservative
methods should be explored prior to
progression to more costly, invasive pro-
cedures.
Some studies have correlated cervi-
cal dysfunction and TMD14,42,43. One
found that following a motor vehicle ac-
cident, chiropractic treatment alone for
cervical spine pain was ineffective; how-
ever, providing the patient with an oc-
clusal orthotic relieved the pain with
continued chiropractic care14. Although
this study evaluated chiropractor inter-
vention, it appears there would be a
similar correlation with physical ther-
apy treatment for cervical pain follow-
ing a motor vehicle accident. There is
significant research supporting the use
THE JOURNAL OF MANUAL & MANIPULATIVE THERAPY Q VOLUME 17 Q NUMBER 4
of physical therapy for cervical dysfunc-
tion, but more definitive research needs
to objectively assess the effectiveness of
cervical treatment for TMD pain and
the reciprocal relationship.
Current evidence supports the use
of physical therapy for TMD patients,
but more evidence-based research is
needed to firmly establish the role of the
physical therapist. Both authors here en-
courage well-trained physical therapists
to inform the dentists in their commu-
nity about their interest and education
in providing TMD treatments for the
dentist’s TMD patients, enabling the
dentist to establish an effective team ap-
proach for these patients.
Summary
TMD is similar to musculoskeletal dis-
orders in other parts of the body, and
similar therapeutic approaches can gen-
erally be used. It is important for dentists
to rule out disorders that mimic TMD,
to identify non-TMD disorders that may
negatively impact the patient’s TMD
symptoms, and to offer the patient ther-
apies that will provide the most cost-ef-
fective long-term symptom relief.
Physical therapists may find the
maps in Figure 4 helpful for identifying
the true source of referred pain. They
may want to provide the dentists who
treat TMD patients in their community
with a copy of Table 1 (situations when
it is recommended that practitioners
consider referring TMD patients to a
physical therapist)2. They should also be
cognizant of potential situations when it
may be prudent to refer a TMD patient
to a dentist (Table 2)30. Physical thera-
pists may also want to improve their
skills in treating TMD patients (see be-
low).
Sources for Physical Therapists to
Obtain Additional TMD Training
There are two known physical therapy
certifying programs for TMD. The first
is the Certified Cervical and Temporo-
mandibular Therapists (CCTT) from
the American Academy of Orofacial
Pain website (visit http://www.aaop
.org/ and select Physical Therapists—
PTBCCT). The other is the Cranio-Fa-
cial Certification (CFC) from the Uni-
versity of St. Augustine (http://www.usa.
edu/ and select Continuing Education/
Certification Programs/Cranio-man-
dibular Head, Neck, and Facial Pain
(CFC).
How Physical Therapists Can Find
TMD-Trained Dentists
Dentists’ abilities to evaluate and treat
TMD vary greatly with their experience
and training. Many postgraduate pre-
sentations, courses, and fellowship pro-
grams are available. Most fellowship
programs have physical therapist and
psychologist faculty members, so these
graduates are well versed in working
with these therapists and in referring
patients to medical colleagues.
The American Dental Association
does not recognize TMD or orofacial
pain as a dental specialty, so dentists are
not permitted to advertise themselves as
a “specialist” in this area. To find a den-
tist with TMD expertise near your office,
visit www.abop.net and select Diplo-
mate Directory.
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